Segmenting Healthcare into “Luxury” and “Value” Brands… Thoughts On Not Getting Stuck in the Middle.

A few months ago, I wrote about how healthcare is poised to segment according to cost and service levels– and that we will likely begin to see healthcare brands emerge that appeal to price-conscious consumers looking for reliable, basic care. My suspicion was that US healthcare is now facing its “Southwest Airlines” moment, where nimble and lean competitors will soon undercut inefficient legacy systems for market share.

What I hadn’t considered is how this segmentation is probably going to squeeze “middle of the road” healthcare brands. That, as with most retail in America today, “value” brands and “luxury” brands are going to thrive while the middle gets squeezed. It’s the same trends that have led to the simultaneous growth of both WalMart and Louis Vuitton into the world’s most valuable brands over the past decade, just as Sears and JC Penny slowly die.

This insight came to me last week, as I found myself grounded by a pilot’s strike at Lufthansa, Germany’s national airline.

Regular readers of my blog know that I often look to the airline industry as a harbinger of what might happen in healthcare over the next few years.

Doctors groan when I tell them this: the similarities between healthcare and aviation are significant: both are both inherently risky ventures that need to be aggressively customer- facing. Both feel the competing pulls of regulation versus free enterprise and both are heavily exposed to enormous environmental and business uncertainties, while being enormously capital intensive.

Luftansa’s response to its own “middle squeeze” was an inconvenient lesson, for me and other travelers. Lufthansa pilots were on strike for the fourth time in a few months and hundreds of flights had been cancelled. Phone lines were overwhelmed and rebooking was impossible.

The strike, by the pilot’s union “Vereinigung Cockpit” was ostensibly due to a pension dispute, but the story is more complicated. The CBC writes:

Lufthansa has been trying to find savings in the face of stiff competition from European budget airlines like Ryanair and EasyJet and major Gulf airlines like Emirates, Etihad and Qatar Airways. The German government, alongside France, is also pressing the European Union to demand a fair playing field with the Gulf airlines, which are accused of receiving billions in states subsidies. Lufthansa operates lower-cost carriers Germanwings and Eurowings, and announced it will add budget long-haul services at the end of the year in collaboration with SunExpress, a joint venture with Turkish Airlines.

The CBC piece doesn’t mention an even more profound disruption that has happened at Lufthansa: Over the past three years, it has moved all shorthaul traffic from the legacy Lufthansa fleet to GermanWings, its low-cost subsidiary. Going forward, Lufthansa will only serve the Munich and Frankfurt markets in Germany, effectively turning Lufthansa into an international and domestic feeder airline. All non-feeder flights, say from Dusseldorf to Stutgart will now be handled by GermanWings, Lufthansa’s low-cost subsidiary. Wikipedia notes:

By the end of 2014 all of Lufthansa’s national routes and international traffic to and from Germany – except all flights to and from Frankfurt and Munich and both Lufthansa long-haul routes from Düsseldorf (to Newark and Chicago) – has been taken over by Germanwings. The last route that was handed over from Lufthansa to Germanwings was Düsseldorf-Zurich on 8 January 2015.

Imagine that: To survive, a legacy airline has had to reinvent itself by getting out of the “middle”.It now serves the lucrative international business crowd on one side (competing with well subsidized Middle Eastern flag carriers) and the budget crowd on the other, reducing overhead and services to compete with low cost air carriers like RyanAir. Lufthansa simply can no longer make a margin selling high-overhead products to price sensitive consumers.

No wonder the pilots are having a meltdown.

So how does this play out in US healthcare?

I’d make the argument that we’re about to see real market segmentation in the US healthcare market. We’ll see a very few flagship healthsystems that will continue to receive “subsidies” (high copays, preferential rates, international patients) to deliver well-pedigreed care, particularly cancer and pediatric services. These will be “luxury” options.

We’ll also see the emergence of cost-transparent and highly efficient systems that deliver consistent, high-quality routine care.

The flabby, underperforming and expensive “middle” players will restructure or be out of business.

Who’s in the flabby middle?

Here’s a pictogram from the Massachusetts Health Policy Commission’s 2014 Cost Trends Report. It reports the average spending for an elective hip replacement in Massachusetts. For hips, prices varied from $26,200 to $41,700…. In many cases more then a well-respected local orthopedic specialty hospital which costs $30,000. The AMCs, and hospitals with a corporate affiliation to an AMC are squarely higher-priced than average.

At the same time, the report notes

Available data do not demonstrate that care is better at higher-paid hospitals. Using [CMS] readmission and complication rates for joint replacements for Medicare fee-for-service (FFS) beneficiaries at acute-care facilities, which includes both high and low risk patients, we found similar quality among all hospitals studies.

The market can only support so many luxury brands. As the middle slims down, there will be howls of protest as compensation, benefits and work expectations are restructured.

I can only imagine what the health care workers of “Vereinigung Hospital” will have to say to the new order.

“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.